The Process Recording

The process recording is a written account of an interaction between a client and nurse. Through the
reconstruction of the interaction the student is provided with an opportunity to retrospectively examine
and analyze his/her communication skills, therapeutic use of self and the client's part in the interaction.
The process recording is used to evaluate both client and student behaviors and approaches

The nurse analyzes what is said (the content of the interaction) and the flow of the interaction (the
process). This analysis augments the nurse's ability to increase awareness of feelings, values,
expectation and assumptions. He or she is able to analyze verbal and non-verbal responses. Process
recordings help caregivers to distinguish between thoughts and feelings.

Client behavior can be retrospectively examined and analyzed with the process recording. Congruency
of verbal and non-verbal behaviors is identified.

Discuss the terms of completion of your process recording with your clinical instructor. A scoring rubric
is attached to guide your completion and to define the scoring of this exercise by your instructor. Submit
your process recording on the attached process recording sheets.

Process Recording Guidelines for Completion

1. Enter the data at the top part of the sheet. The recording is to be made on a meeting with your
client. Before the meeting with the client, develop a short-term goal that is client centered and
that will serve as a guideline and purpose for the communication/session. The length of time of
any given session can vary from 10 minutes to one hour. Refer to your Psychiatric Nursing or
Fundamentals of Nursing Textbooks as available in preparation for your process recording with
your client (i.e. review of Therapeutic Communication Techniques).

2. Column One/Setting: Describe the setting and your plans to therapeutically approach the client
at the beginning of the session with sufficient clarity and detail so that the instructor will be
helped in his/her understanding of the situation. The setting includes a description of the
physical environment, time, position of you and the client and any other pertinent details. The
therapeutic approach includes the verbal and nonverbal therapeutic communication techniques
you plan to utilize during the interaction.

3. Columns Two & Three/Verbal and Non-Verbal Communication Student and Client: The
nonverbal communication of both you and the client is as important as the verbal
communication. Identify the nonverbal communication. Is there congruence between the verbal
and nonverbal communication? Recording of verbal communication should be verbatim. If the
meeting includes a period of an activity that you participate in with the client, record only the
beginning, the termination, and what you consider significant material in the remaining time.

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 4. Column Four/Student’s thoughts and feelings concerning the interaction: Describe your
reactions to the communication. What kind of emotions did you feel and why? Were you at ease
or uncomfortable? Did you feel you had to struggle to remain objective? Did you feel like you
could help the client? Did you feel confident at the end of the communication?

5. Column Five/Evaluation/Analysis of the Interaction/include therapeutic techniques/approach

applied:
a. Your perception of the client's feelings and behaviors
b. Defense mechanisms used by the client
c. Client's level of insight into problems
d. Client’s Anxiety level
e. Outcomes of therapeutic techniques used
f. Alternatives to therapeutic techniques
g. Assess the client's needs and your ability to meet one or more of them
h. Analyze the effectiveness of the communication to the best of your ability.

 Nurses must be able to demonstrate interpersonal and therapeutic communication skills that
result in information exchange and effective care within the context of the nursing process.

 Nursing students utilize therapeutic communication techniques in providing care to individuals,

families, and groups with increasingly complex health care problems.

The following criteria will be applied by your instructor to evaluate your process recording. Utilize these
criteria to assist you to meet the expectations of the course to the best of your ability. An overall
number is assigned to your process recording on the basis of these criteria as indicated below; four is
the highest level of evaluation and one is the lowest.

RUBRICS IN GRADING YOUR PROCESS RECORDING

4  Process recording reflects consistent and skillful use of varied therapeutic
communication techniques.
 The student accurately describes the setting and the goal of the interaction.
 Student demonstrates therapeutic use of self and is aware of the appropriateness of
his /her own responses.
 The student is able to identify thoughts and feelings concerning the interaction.
 The student is able to identify blocks to the therapeutic communication process. The
student is able to identify the patient’s verbal and nonverbal communication.
 The student is able to analyze the content and pattern of communication. The student
demonstrates cooperation, respect and courtesy.
 Reflection and documentation regarding the effectiveness of the communication are
evident.
3  Process recording reflects use of many therapeutic communication techniques.
 The student includes a description of the setting and goal for the interaction.
 The student demonstrates self-awareness and identifies thoughts and feelings.
 The student shows competence with use of communication techniques.

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  The student identifies client communication patterns. Documentation and reflection
reflect attainment of the goal.
 “That should help you learn how to keep your numbers up. You can work at breathing
better and maybe you will not need the oxygen at home afterwards.”
 “Okay. I will let you rest now and I will check in on you in a little while.”
 “That would be good. I don’t like all the tubes on the floor to trip on.”
 She’s looking around at the coil of tubing on the floor and then picking it up to gather
it into one clump.
 “I want to try walking again later without the oxygen on. After I rest a while.”
“Thanks.”
 I can see she is done talking about this topic. and wanting to remain independent of
oxygen once she leaves the hospital. Once I saw the way she was thinking, I thought it
best to encourage her in her efforts to stop smoking and also to see the value of
pulmonary rehab.
 Since this patient has a habit of changing topics quickly and having scattered thoughts,
I was not surprised to have the conversation go the way it did

2  Process recording reflects use of some communication techniques.

 There is evidence of basic use of therapeutic communication techniques.
 The student misinterprets or fails to address the verbal and nonverbal cues of the
patient.
 The student occasionally responds in a non-therapeutic manner (ie. giving advice or
false reassurance).
 Communication lacks clarity, flow and goal orientation.
 Student exhibits limited awareness regarding therapeutic use of self or thoughts and
feelings regarding the interaction. Reflection and documentation are superficial.
1  Process recording reflects minimal use of therapeutic communication techniques.
 Communication lacks focus, clarity and does not address the bio/psycho/social needs
of the client.
 Blocks to communication are not addressed.
 The conversation is student nurse centered rather than client centered. The student
does not exhibit insight or self-awareness regarding the interaction.
 Reflection and documentation is minimal.

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Sample Process Recording
(The form must be written in your lesson plan notebook)

PROCESS RECORDING
CLIENT INITIALS: Rogelynn PERTINENT NURSING DIAGNOSIS/DIAGNOSES :
AGE: 72 Activity intolerance related to COPD as evidenced
GENDER: M DATE: __________ by SOB on exertion and patient oxygen saturation
MEDICAL/SURGICAL DIAGNOSIS: COPD declining during ambulation.
exacerbation
SHORT TERM GOAL(S)
Patient will verbalize strategies for maintaining
STUDENT NAME: ______________ oxygen saturation >88% while participating in
physical activity by the end of her hospital
stay.___________
SETTING VERBAL & VERBAL & NONVERBAL STUDENT’S THOUGHTS AND EVALUATION/ANALYSIS
NONVERBAL COMMUNICATION: FEEINGS CONCERNING THE OF THE INTERACTION
COMMUNICATION: CLIENT INTERACTION INCLUDE THERAPEUTIC
STUDENT APPROACH/TECHNIQUES
APPLIED
Patient’s room just I make eye contact I want her to feel that I am
after returning from with patient and willing to listen to what she has
walking in hallway. make sure my arms to say to me.
Patient has O2 by are not crossed.
NC and has used O2
sat. monitor. “How did you feel Patient looks at me and She was really focused on the Trying to use open ended
Patient sits in chair while walking in the answers: “Pretty good, but I O2 sat monitor while we questions.
and I am facing her. hallway?” kept worrying about my walked.
My plan is to numbers dropping.”
discuss strategies
for maintaining O2 “Your numbers were “Yeah, but they are talking She really doesn’t want to have Showing interest in what
sat during activity. better today than about me wearing this to be dependent on oxygen at she has to say and letting
yesterday, so that is (pointing to O2 tubing) at home. her lead the conversation
some improvement.” home, too.” so I can get more
information about how
she is thinking about the
topic of oxygen at home.

“What do you think “I don’t want to have to drag She seems pretty upset with
about that?” this around with me herself and realizes that her
wherever I go. I should have choice to smoke got her in this
listened to my doctor when situation.
he told me to stop smoking
all those times. But I just
didn’t listen. Now look where
that got me.”
“You have stopped “I guess.” I am trying to be positive about
smoking now, so that the progress and changes that
is a start.” she has made, so she will not be
so discouraged. I think that she
will give up on positive things if
she feels they will not make a
difference.

“I hear you are going She is starting to fiddle with She seems to be losing interest

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 to go to pulmonary things on her table and in this topic.
rehab after you leave rearrange them.
the hospital. What
do you know about
it?”

“It’s outpatient for two hours She seems interested in going. My goal was to try to
at a time. It’s about 30 That’s good. If she’s interested teach her about pacing
minutes from my house, so then she will get more out of it. herself with activity and
my husband will be able to breathing effectively
get me there.” while walking. The topic
turned to her dislike of
the oxygen tubing
“That should help “That would be good. I don’t and wanting to remain
you learn how to like all the tubes on the floor independent of oxygen
keep your to trip on.” once she leaves the
hospital. Once I saw the
numbers up. You
way she was thinking, I
can work at thought it best to
breathing better She’s looking around at the encourage her in her
and maybe you coil of tubing on the floor and efforts to stop smoking
will not need the then picking it up to gather it and also to see the value
oxygen at home into one clump. of pulmonary rehab.
afterwards.”

Since this patient has a

I can see she is done talking habit of changing topics
I want to try walking again about this topic. quickly and having
“Okay. I will let later without the oxygen on. scattered thoughts, I was
you rest now and I After I rest a while.” not surprised to have the
will check in on conversation go the way
you in a little “Thanks.” it did.
while.”

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